Please complete the form on this page to send your information to our clinic.
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AUTHORIZATION AND RELEASE: I authorize payment of automobile insurance benefits directly to the chiropractor or naturopathic office. I authorize the doctor(s) to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs of care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.
The patient understands and agrees to allow this Active Lifestyle Clinic to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.
It has become standard practice in the Health Care Industry and a requirement of the State of Arizona per Statute 33-931 and 33-932 to file what is known as “Notice and Claim of Health Care Provider Lien”. These liens must be recorded with the County Recorder’s Office, by law. A copy will be sent to you for your records and will be released when we receive payment in full.
Please be assured that this is not a lien against you, or your property. This is not a reflection on your integrity and will not be picked up by credit reporting agencies for any reason, as this lien is not against you the patient, but merely a lien for payment from the responsible insurance company for your medical care costs.
At the time of settlement of your case you may receive a check/draft made out jointly to you and the Doctor, at which time you are required to promptly bring the check/draft to our office for disbursement of funds.
If you have an attorney, the check may be made out to you and your attorney. Your attorney must sign an indemnifying agreement with the insurance company to pay any and all liens in full (we do not typically negotiate to reduce our fees). If for some reason your settlement does not cover the cost of your care, you are personally responsible and agree to pay the balance of the bill in full.
Our Clinic Address:16515 South 40th Street #131Phoenix, AZ 85048Click Here to Map It!
Our Office Hours:
Monday, Wednesday, Friday:8:30 a.m. to 6:00 p.m.
Tuesday:7:00 a.m. to 12:00 p.m. (noon)
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